Persistent Prescribing of Risky Medications to Older Adults with Dementia: A Concern for Patient Safety
Despite years of clinical guidelines warning against the practice, one in four Medicare beneficiaries with dementia is prescribed brain-altering medications linked to falls, confusion, and hospitalization, according to new research to be published January 12 in the peer-reviewed journal JAMA. This study highlights a persistent issue that needs urgent attention.
While prescriptions for these medications fell from 20% to 16% over the nine-year study period among all Medicare beneficiaries, they continue to be prescribed to individuals with cognitive impairment who are particularly susceptible to these ill effects. The research reveals a concerning trend: over two-thirds of patients receiving these prescriptions lacked a documented clinical indication in 2021, suggesting high levels of potentially inappropriate and harmful prescribing.
Dr. John N. Mafi, a senior author of the study, emphasizes the need for improvement in the quality and safety of care for older Americans. The study used survey data from the Health and Retirement Study linked to Medicare fee-for-services claims to trace CNS-active prescribing patterns between January 1, 2013, and December 31, 2021, among older adults with normal cognition, cognitive impairment without dementia, and dementia.
The CNS-active medications studied included five drug classes: antidepressants with strong anticholinergic properties, antipsychotics, barbiturates, benzodiazepines, and non-benzodiazepine hypnotics. While CNS medications were prescribed for 17% of older adults with normal cognition, nearly 22% of those with cognitive impairment but without dementia were given the drugs. About 25% of the group with dementia were prescribed the CNS-active medications.
The study found that benzodiazepines declined by 11.4% to 9.1%, nonbenzodiazepine hypnotics fell from 7.4% to 2.9%, antipsychotic medication prescriptions rose from 2.6% to 3.6%, and prescriptions for anticholinergic antidepressants remained at 2.6% through the study period. Barbiturate prescriptions fell slightly from 0.4% to 0.3%.
Clinically justified prescriptions fell from 6% in 2013 to 5.5% in 2021, while likely inappropriately prescribed CNS-active medications saw a significant decline from 15.7% to 11.4%. The improvement was driven largely by reductions in prescriptions for benzodiazepines and sleep medications as well as in inappropriate prescriptions.
The findings are limited by unavailable Medicare Advantage data, possibly missing clinical information such as agitation, and a focus on prescribing prevalence rather than cumulative exposure. Dr. Annie Yang, a scholar in the National Clinician Scholars Program at Yale University, emphasizes the importance of patients and their care teams working closely with their physicians to ensure that these medications are appropriate to their cases.
The study's co-authors include Mei Leng, Dr. Dan Ly, Chi-Hong Tseng, Dr. Catherine Sarkisian, and Nina Harawa of UCLA; Cheryl Damberg of RAND, and Dr. A. Mark Fendrick of the University of Michigan. The National Institutes of Health/National Institute on Aging funded the study.
This research highlights a critical issue in patient safety and underscores the need for further investigation and action to ensure that older adults with dementia receive appropriate and safe medical care.
